<p> Work Experience Placement – Application Form</p><p>The information provided will be treated in the strictest confidence</p><p>Personal Details</p><p>Title: Forename: Surname:</p><p>D.O.B: Age: Telephone(s):</p><p>Address:</p><p>Postcode:</p><p>Email Address:</p><p>Education Name of School/College/University: Name of careers Advisor: Telephone:</p><p>Placement Details Please indicate your preferred placement details below;</p><p>Preferred Site Royal Albert Edward Infirmary Leigh infirmary Wrightington Hospital </p><p>Placement Type Nursing Medical Scientific Admin Estates & Anciliary Comments / Career aspirations:</p><p>Duration of placement Required 1 Week 2 Weeks</p><p>Dates Available, Please be specific, rather than stating academic terms, detailing first and second choices where applicable. Course Information Please provide information about the courses you are studying and your expected grades: Subject Expected Grade Subject Expected Grade</p><p>Supporting Information Please use the space below to provide any relevant information in support of your application:</p><p>Confidentiality Statement Please read the following statement and sign the declaration below:</p><p>If your application for work experience is successful, you may have access to sensitive information regarding patients. It is important to retain said information in a confidential manner under the Data Protection Act 1998. Furthermore, you must not access information or material that you have received no instruction to do so. Failure to adhere to this may breach other individuals’ rights to privacy and in turn may be deemed an act of criminality. </p><p>By submitting this application for work experience, you acknowledge that you have read the above statement and have agreed to its terms in regard to your visit to the Trust. Student Name: Date:</p>